1679688675 NPI number — BRENDA LEIGH INGRAM PA-C

Table of content: BRENDA LEIGH INGRAM PA-C (NPI 1679688675)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679688675 NPI number — BRENDA LEIGH INGRAM PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
INGRAM
Provider First Name:
BRENDA
Provider Middle Name:
LEIGH
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HALE
Provider Other First Name:
BRENDA
Provider Other Middle Name:
LEIGH
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA-C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1679688675
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/10/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 841656
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75284-1656
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-531-5000
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
115 AIRPORT RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SULPHUR SPRINGS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75482-2105
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-885-7671
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  PA03143 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: P01761904 . This is a "RAIL ROAD MEDICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 75-2616977-002 . This is a "TRICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 75-2616977-129 . This is a "TRICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 8478MA . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 313744004 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 313744006 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 75-2616977-001 . This is a "TRICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 8479MA . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: P01762486 . This is a "RAIL ROAD MEDICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 75-0818167-015 . This is a "TRICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 75-0818167-044 . This is a "TRICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 75-0818167-048 . This is a "TRICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 75-2616977-028 . This is a "TRICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 313744005 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 75-0818167-022 . This is a "TRICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 75-1976930-005 . This is a "TRICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 313744007 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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